The eye is a mirror which reflect the health of other systems in the human body. The human eye, as an organ, can offer critical clues to the diagnosis of various systemic illnesses. Ocular changes are common in various endocrine disorders such as diabetes mellitus and Graves’ disease. Awareness of the associations between the ocular manifestations and endocrine disorders is the first step in the diagnosis and management of these complex patients.

1. SYSTEMIC DISEASESSYSTEMIC DISEASES
ASSOCIATED WITHASSOCIATED WITH
THE EYETHE EYE
Presented byPresented by DR. ARMAAN SINGHDR. ARMAAN SINGH

2. ENDOCRINE DISORDERSENDOCRINE DISORDERS
ASSOCIATED THE EYEASSOCIATED THE EYE

3. FOREWORDFOREWORD
• The eye is aThe eye is a mirrormirror which reflect the health of other systems in the humanwhich reflect the health of other systems in the human
body.body.
• The human eye, as an organ,The human eye, as an organ, can offer critical clues to thecan offer critical clues to the
diagnosisdiagnosis of various systemic illnesses.of various systemic illnesses.
• Ocular changes are common in various endocrine disorders such asOcular changes are common in various endocrine disorders such as
diabetes mellitus and Graves’ disease.diabetes mellitus and Graves’ disease.
• Awareness of the associations between the ocular manifestations andAwareness of the associations between the ocular manifestations and
endocrine disorders isendocrine disorders is the first step in the diagnosis andthe first step in the diagnosis and
management of these complex patients.management of these complex patients.

5. PITUITARY GLANDPITUITARY GLAND

6.  PITUITARY TUMORSPITUITARY TUMORS
 Foreword:Foreword:
• Pituitary tumors arePituitary tumors are benign growths of cellsbenign growths of cells in the pituitary gland .in the pituitary gland .
• Small tumors of the pituitary are very common and usually without symptoms,Small tumors of the pituitary are very common and usually without symptoms,
unless the tumor produces a hormone.unless the tumor produces a hormone.
• However if the tumor enlarges,:However if the tumor enlarges,:
it can cause hormonal deficiencies by pressing on the normal pituitaryit can cause hormonal deficiencies by pressing on the normal pituitary
cells.cells.
 If it grows even larger (> 1 cm), it can cause visual symptoms.If it grows even larger (> 1 cm), it can cause visual symptoms.

7. Ocular symptoms:Ocular symptoms:
Depending on the sizeDepending on the size
of a pituitary tumor,of a pituitary tumor,
visual symptoms mayvisual symptoms may
include:include:
•• Blurred vision (in one or bothBlurred vision (in one or both
eyes)eyes)
•• Loss of peripheral visionLoss of peripheral vision
•• Double visionDouble vision

8. A pituitary tumor can cause visualA pituitary tumor can cause visual
symptoms arising from :symptoms arising from :
Pressure effects exerted on the opticPressure effects exerted on the optic
nerves, chiasma, or tracts.nerves, chiasma, or tracts.
Extension of the tumor into theExtension of the tumor into the
cavernous sinus can lead to paresiscavernous sinus can lead to paresis
of the third, fourth, or sixth nerves,of the third, fourth, or sixth nerves,
causing disorders of extraocularcausing disorders of extraocular
movement.movement.

9. Double vision :Double vision :
Can occur when the normal eyeCan occur when the normal eye
movements are affected.movements are affected.

10. Visual field defect in pituitaryVisual field defect in pituitary
tumor:tumor:
• are caused by tumor compressionare caused by tumor compression
on the optic nerve or chiasm.on the optic nerve or chiasm.
• Depending on theDepending on the sizesize andand
locationlocation of the tumor.of the tumor.
• The severity and symmetry of theThe severity and symmetry of the
visual field defect may vary as wellvisual field defect may vary as well
as the anatomical relationship of theas the anatomical relationship of the
chiasm to the pituitary stalk.chiasm to the pituitary stalk.

12. TYPES OF VISUAL FIELD DEFECTTYPES OF VISUAL FIELD DEFECT
 Monocular Visual Field Deficit.Monocular Visual Field Deficit.
 Chiasmal Field Deficit.Chiasmal Field Deficit.
 Junctional Field Deficits.Junctional Field Deficits.

13.  Monocular Visual Field Deficit:Monocular Visual Field Deficit:
• Asymmetric tumors may involveAsymmetric tumors may involve
one side of the chiasm or an opticone side of the chiasm or an optic
nerve, and most commonly presentsnerve, and most commonly presents
as a supertemporal quadrantanopsia.as a supertemporal quadrantanopsia.

14. Chiasmal Field Deficit:Chiasmal Field Deficit:
• lesions at the level of the opticlesions at the level of the optic
chiasm produce a bitemporal hemianopia.chiasm produce a bitemporal hemianopia.
• Pituitary adenomas, which growPituitary adenomas, which grow
upward from the pituitary stalk,upward from the pituitary stalk,
compress the chiasm from below, whichcompress the chiasm from below, which
preferentially involves the inferior, nasal,preferentially involves the inferior, nasal,
and macular nerve fibers. This correspondsand macular nerve fibers. This corresponds
to superior, bitemporal, and central vision loss.to superior, bitemporal, and central vision loss.

15. Junctional Field Deficits:Junctional Field Deficits:
• central scotoma in one eye withcentral scotoma in one eye with
temporal visual field loss in the other eye .temporal visual field loss in the other eye .
•It caused by compression to an anteriorIt caused by compression to an anterior
loop to the decussating nasal fibersloop to the decussating nasal fibers
within the posterior optic nervewithin the posterior optic nerve
"Wilbrand's knee,""Wilbrand's knee,"

16. Diagnosis:Diagnosis:
 The doctor will examine:The doctor will examine:
•• Visual acuityVisual acuity
•• Color visionColor vision
•• Peripheral vision .Peripheral vision .
•• Eye movementsEye movements
•• The appearance of theThe appearance of the
retina and optic nerve .retina and optic nerve .

17.  Papilledema is aPapilledema is a rarerare finding in pituitary tumors.finding in pituitary tumors.
because of the slow –growing nature of these tumors whichbecause of the slow –growing nature of these tumors which
cause secondary optic atrophy before the tumor enlargescause secondary optic atrophy before the tumor enlarges
sufficiently to increase ICP.sufficiently to increase ICP.

19. Treatment:Treatment:
 may include:may include:
 Surgery.Surgery.
 Medications to shrink theMedications to shrink the
tumor (depending on the typetumor (depending on the type
of tumor cells).of tumor cells).
 Radiation treatmentRadiation treatment

20. Treatments for double visionTreatments for double vision
include:include:
•• Blocking the vision from one eye.Blocking the vision from one eye.
•• Prisms in eyeglasses.Prisms in eyeglasses.
•• Surgery on eye muscles to correctSurgery on eye muscles to correct
the alignment of the eyes.the alignment of the eyes.

21. Prognosis:Prognosis:
• Visual loss :Visual loss :
oftenoften improveimprove after a pituitary tumor is treated.after a pituitary tumor is treated.
Or may beOr may be permanentpermanent if it has been present for a long time or isif it has been present for a long time or is
severe.severe.
• Visual field:Visual field:
 The pattern of recovery after decompression suggests at least threeThe pattern of recovery after decompression suggests at least three
phases of improvement.phases of improvement.

22.  The three phases of improvement :The three phases of improvement :
 TheThe early fastearly fast phase (surgery to 1 week) may lead to normalizationphase (surgery to 1 week) may lead to normalization
in some individuals.in some individuals.
 TheThe early slowearly slow phase (1-4 months) is the period of most notablephase (1-4 months) is the period of most notable
improvement .improvement .
 AA latelate phase (6 months to 3 years) of mild improvement doesn'tphase (6 months to 3 years) of mild improvement doesn't
appear significant over all but maybe marked in some individuals.appear significant over all but maybe marked in some individuals.

23.  the most common Hypothalmic –pituitarythe most common Hypothalmic –pituitary
syndromessyndromes
 Septo-optic dysplasia (SOD).Septo-optic dysplasia (SOD).
 Kallman's syndrome.Kallman's syndrome.
 Empty sella syndrome.Empty sella syndrome.
Oliver Mcfarlane syndrome.Oliver Mcfarlane syndrome.

24. Septo-optic dysplasia (SOD):Septo-optic dysplasia (SOD):
 It is a rare congenital anomalyIt is a rare congenital anomaly
The classical triad of SOD includes:The classical triad of SOD includes:
(i) optic nerve hypoplasia .(i) optic nerve hypoplasia .
(ii) pituitary hormone abnormalities.(ii) pituitary hormone abnormalities.
(iii) midline brain defects.(iii) midline brain defects.
 Diagnosis of SOD can be made clinicallyDiagnosis of SOD can be made clinically
when two or more features of the triad are present.when two or more features of the triad are present.

25. Ocular manifestations:Ocular manifestations:
• varying degrees of visual impairment.varying degrees of visual impairment.
• microphthalmia or anophthalmia.microphthalmia or anophthalmia.
• optic nerve dysplasia, or hypoplasia (wherein the optic nerveoptic nerve dysplasia, or hypoplasia (wherein the optic nerve
appears small and pale).appears small and pale).
NNoteote...The presence of strabismus or nystagmus in a child at...The presence of strabismus or nystagmus in a child at
birth with multiple congenital abnormalities should alert anbirth with multiple congenital abnormalities should alert an
ophthalmologist to seek the opinion of an endocrinologist.ophthalmologist to seek the opinion of an endocrinologist.

26. Kallman's syndrome:Kallman's syndrome:
A rare genetic disorder.A rare genetic disorder.
It consists of :It consists of :
defective gonadotropin-releasing hormone synthesis.defective gonadotropin-releasing hormone synthesis.
 olfactory nerve agenesis or hypoplasia.olfactory nerve agenesis or hypoplasia.
Ocular manifestations:Ocular manifestations:
• optic atrophy.optic atrophy.
• color blindness.color blindness.
• oculomotor abnormalities.oculomotor abnormalities.

27. Empty sella syndrome:Empty sella syndrome:
 Is defined as an intrasellar herniation of the suprasellar space withIs defined as an intrasellar herniation of the suprasellar space with
compression of the pituitary gland.compression of the pituitary gland.
 Is classified as :Is classified as :
PrimaryPrimary… caused by combination of:… caused by combination of:
• Incomplete diaphragma sella.Incomplete diaphragma sella.
• An increased CSF fluid pressure.An increased CSF fluid pressure.
SecondarySecondary…when it discovers following pituitary radiation or…when it discovers following pituitary radiation or
pituitary surgery.pituitary surgery.

29. Ocular manifestations:Ocular manifestations:
• Diminished visual acuityDiminished visual acuity ..
• Visual field defectsVisual field defects such as peripheral field constriction,such as peripheral field constriction,
bitemporal hemianopia, or quadrantanopia.bitemporal hemianopia, or quadrantanopia.
NNote…... Patients with secondary empty sella predominantlyote…... Patients with secondary empty sella predominantly
present with visual abnormality occurring due to arachnoidalpresent with visual abnormality occurring due to arachnoidal
adhesions and traction on the optic chiasma.adhesions and traction on the optic chiasma.

30.  Oliver Mcfarlane syndrome:Oliver Mcfarlane syndrome:
 It is an extremely rare condition associated with :It is an extremely rare condition associated with :
chorioretinal degenerationchorioretinal degeneration, patients usually present with marked, patients usually present with marked
decrease in vision.decrease in vision.
Dwarfism with growth hormone deficiency.Dwarfism with growth hormone deficiency.
Hair abnormalities.Hair abnormalities.
 Cerebellar dysfunction.Cerebellar dysfunction.

31. THYROID EYE DISEASESTHYROID EYE DISEASES
 Foreword:Foreword:
An autoimmune conditionAn autoimmune condition, which means that the body’s immune, which means that the body’s immune
system mistakenly targets its own tissues.system mistakenly targets its own tissues.
 It occurs with :It occurs with :
 an overactive thyroid in :an overactive thyroid in :
 Grave’s disease.Grave’s disease.
 Toxic nodular goitre.Toxic nodular goitre.
 Hypothyroidism, for exampleHypothyroidism, for example
with Hashimoto’s disease.with Hashimoto’s disease.

32. GRAVES’ DISEASEGRAVES’ DISEASE
 Foreword:Foreword:
• Autoimmune diseaseAutoimmune disease, in which immunoglobulins are directed, in which immunoglobulins are directed
against the TSH receptors on the thyroid cellular membrane.against the TSH receptors on the thyroid cellular membrane.
• Most common form of thyrotoxicosis.Most common form of thyrotoxicosis.
• May occur at any age but mostly fromMay occur at any age but mostly from 20-4020-40..
• Is a condition that predominantly affectsIs a condition that predominantly affects females.females.

33.  Clinical features:Clinical features:
I. Eye features.I. Eye features.
II. Goitre.II. Goitre.
III. Thyroid dermopathy (pretibial myxedema).III. Thyroid dermopathy (pretibial myxedema).
IV. Heat intolerance.IV. Heat intolerance.
V. Cardiovascular.V. Cardiovascular.
VI. Gastrointestinal.VI. Gastrointestinal.
VII. Reproductive.VII. Reproductive.
VIII. Bone.VIII. Bone.
IX. Neuromuscular.IX. Neuromuscular.
X. Skin.X. Skin.

34.  Eye features:Eye features:
Classes 0-6, mnemonicClasses 0-6, mnemonic “NO SPECS”“NO SPECS”
• Class 0:Class 0: NNo signs or symptoms.o signs or symptoms.
• Class 1:Class 1: OOnly signs (lid retraction, stare, lid lag), no symptoms.nly signs (lid retraction, stare, lid lag), no symptoms.
• Class 2:Class 2: SSoft tissue involvement (periorbital edema, congestionoft tissue involvement (periorbital edema, congestion
or redness of the conjunctiva, and chemosis).or redness of the conjunctiva, and chemosis).
• Class 3:Class 3: PProptosis .roptosis .
• Class 4:Class 4: EExtraocular muscle involvement.xtraocular muscle involvement.
• Class 5:Class 5: CCorneal involvement.orneal involvement.
• Class 6:Class 6: SSight loss (optic nerve involvement).ight loss (optic nerve involvement).

35. Lid lag in downgaz lid retractionLid lag in downgaz lid retraction

36. CONJUNCTIVAL HYPERAEMIA PERIORBITAL AND LID SWELLINGCONJUNCTIVAL HYPERAEMIA PERIORBITAL AND LID SWELLING
proptosis chemosis

37.  Diagnosis:Diagnosis:
Low TSH, High FT4 and/or FT3.Low TSH, High FT4 and/or FT3.
If eye signs are present, the diagnosis of Graves’ disease can be made withoutIf eye signs are present, the diagnosis of Graves’ disease can be made without
further tests.further tests.
If eye signs are absent and the patient is hyperthyroid with or without a goitre,If eye signs are absent and the patient is hyperthyroid with or without a goitre,
we need other tests for diagnosis (radioiodine, ………).we need other tests for diagnosis (radioiodine, ………).

38. Symptoms and signs influence the managementSymptoms and signs influence the management
strategy so we should assesse:strategy so we should assesse:
The degree of exophthalmos (exophthalmometer).The degree of exophthalmos (exophthalmometer).
the intraocular pressure.the intraocular pressure.
Extraocular muscle thicknessExtraocular muscle thickness
(CT, ultrasonography).(CT, ultrasonography).
The degree of optic nerve compressionThe degree of optic nerve compression
(electroretinogram, cortical visual evoked(electroretinogram, cortical visual evoked
potentials, and color contrast sensitivity ).potentials, and color contrast sensitivity ).

39.  Treatment:Treatment:
• Medical therapy.Medical therapy.
• Surgical therapy.Surgical therapy.
• Radioactive iodine therapy.Radioactive iodine therapy.

40.  Management of opthalmopathy:Management of opthalmopathy:
 Management involves cooperation between the endocrinologistManagement involves cooperation between the endocrinologist
and the opthalmologist.and the opthalmologist.
 KeepKeep head elevatedhead elevated at night to diminish periorbital edema.at night to diminish periorbital edema.
 If the cornea is exposed, it is important to prescribeIf the cornea is exposed, it is important to prescribe artificial tearsartificial tears
as a means of corneal lubrication.as a means of corneal lubrication.

41.  For more severely affected eyesFor more severely affected eyes, immunosuppressive therapy, immunosuppressive therapy
with glucocorticoidswith glucocorticoids benefit approximately 60% of patients withbenefit approximately 60% of patients with
thyroid-associated opthalmopathy.thyroid-associated opthalmopathy.
 If steroid therapy is not effective externalIf steroid therapy is not effective external x-ray therapyx-ray therapy to theto the
retrobulbar area may be helpful.retrobulbar area may be helpful.
 If vision is threatenedIf vision is threatened orbital decompressionorbital decompression ( surgical) can be( surgical) can be
used.used.

42. Hashimoto’s thyroiditisHashimoto’s thyroiditis
•Is a common cause of hypothyroidism and goitre especially in children andIs a common cause of hypothyroidism and goitre especially in children and
young adults.young adults.
•It is anIt is an autoimmune diseaseautoimmune disease ..
•Hypothyroidism usually has an insidious onset : patients present withHypothyroidism usually has an insidious onset : patients present with
complaints of (lethargy, weight gain, dry and thickened skin ………………).complaints of (lethargy, weight gain, dry and thickened skin ………………).
•Ophthalmologic features:Ophthalmologic features:
periorbital swelling (part of the generalized nonpitting skin edema ofperiorbital swelling (part of the generalized nonpitting skin edema of
myxedema).myxedema).
characteristic loss of the outer third of the eyebrow.characteristic loss of the outer third of the eyebrow.
 open-angle glaucoma (deposition of a mucopolysaccharide within theopen-angle glaucoma (deposition of a mucopolysaccharide within the
trabecular meshwork).trabecular meshwork).

43. periorbital swelling loss of the outer third of the eyebrow.

44.  PARATHYROID EYE DISEASEPARATHYROID EYE DISEASE
There are four parathyroid
glands, which are located
behind the thyroid.

45.  Hyperparathyroidism:Hyperparathyroidism:
 Hyperparathyroidism may be subdivided into primary,Hyperparathyroidism may be subdivided into primary,
secondary, tertiary, and pseudohyperparathyroidism.secondary, tertiary, and pseudohyperparathyroidism.
 Hyperparathyroidism causesHyperparathyroidism causes hypercalcemiahypercalcemia can leadcan lead
toto ocular manifestationsocular manifestations ::
calcification of the conjunctiva.calcification of the conjunctiva.
calcified nodules of the eyelids.calcified nodules of the eyelids.
band keratopathy.band keratopathy.

46. Band keratopathy

47. calcification of the conjunctiva.

48.  Hypoparathyroidism:Hypoparathyroidism:
 Is usually the result of the accidental removal of the parathyroidIs usually the result of the accidental removal of the parathyroid
glands duringglands during thyroidectomythyroidectomy, although it may be, although it may be idiopathicidiopathic inin
origin.origin.
 The lack of parathyroid hormone produces a clinical state ofThe lack of parathyroid hormone produces a clinical state of
hypocalcemia and hyperphosphatemia.hypocalcemia and hyperphosphatemia.
 The ocular response to hypocalcemia is:The ocular response to hypocalcemia is:
 cataractogenesis:cataractogenesis:
 At presentation the lens develops subcapsular cataract.At presentation the lens develops subcapsular cataract.
 Which with progression, involves the lenticular cortex.Which with progression, involves the lenticular cortex.
 chronic keratoconjunctivitischronic keratoconjunctivitis (especially in children with idiopathic(especially in children with idiopathic
Hypoparathyroidism ).Hypoparathyroidism ).

49. subcapsular cataractchronic keratoconjunctivitis

50. Adrenal eye diseaseAdrenal eye disease
Cushing's Syndrome:Cushing's Syndrome:
 Excessive production of adrenocortical products.Excessive production of adrenocortical products.
 Ocular involvementOcular involvement is poorly defined and may include :is poorly defined and may include :
 Cataract (posterior subcapsular type) due to prolonged administration ofCataract (posterior subcapsular type) due to prolonged administration of
steroids not a feature of endogenous steroid overproduction.steroids not a feature of endogenous steroid overproduction.
elevation of intraocular pressure.elevation of intraocular pressure.
 hypertensive retinopathy.hypertensive retinopathy.
 proptosis.proptosis.

51.  Addison's Disease:Addison's Disease:
 Caused by insufficiency of theCaused by insufficiency of the
adrenal cortex.adrenal cortex.
 ocular manifestations:ocular manifestations:
 pigmentation involving thepigmentation involving the
eyelids and conjunctiva.eyelids and conjunctiva.
 Papilledema caused byPapilledema caused by
increasedincreased
intracranial pressure.intracranial pressure.

52.  Neuroblastoma:Neuroblastoma:
 Neuroblastomas arise from primitive neuroectodermal elements.Neuroblastomas arise from primitive neuroectodermal elements.
 Patients may present with an abdominal mass and, because most of thesePatients may present with an abdominal mass and, because most of these
tumors secrete catecholamines.tumors secrete catecholamines.
 ocular manifestationocular manifestation ::
orbital metastaticorbital metastatic can present with:can present with:
 proptosis.proptosis.
 subconjunctival hemorrhage .subconjunctival hemorrhage .
 ecchymosis of the eyelids.ecchymosis of the eyelids.
 Horner's syndromeHorner's syndrome, usually associated with, usually associated with heterochromia iridisheterochromia iridis (less(less
common ).common ).

53. ecchymosis of the eyelids heterochromia iridis

54.  Pheochromocytoma:Pheochromocytoma:
 This rare catecholamine-secretingThis rare catecholamine-secreting
tumor originates in chromaffin cells.tumor originates in chromaffin cells.
 The major ophthalmic featureThe major ophthalmic feature
of the conditionof the condition isis hypertensivehypertensive
retinopathyretinopathy with:with:
flame-shaped hemorrhages.flame-shaped hemorrhages.
 cotton-wool spots.cotton-wool spots.
 narrowed arteries.narrowed arteries.
swollen optic discs.swollen optic discs.

55. Gonadal Disorders:Gonadal Disorders:
Turner syndrome:Turner syndrome:
 Turner syndrome is a condition in which there is an absence or structuralTurner syndrome is a condition in which there is an absence or structural
abnormality of one X chromosome in phenotypic females.abnormality of one X chromosome in phenotypic females.
 Ocular manifestations:Ocular manifestations:
 strabismusstrabismus
 ptosisptosis
 hypertelorism.hypertelorism.
 epicanthus.epicanthus.
 red–green color deficiency.red–green color deficiency.
 Ocular hypertension and glaucoma.Ocular hypertension and glaucoma.

57. Klinefelter's syndrome:Klinefelter's syndrome:
 Is the most frequent form of sex chromosome aneuploidy.Is the most frequent form of sex chromosome aneuploidy.
 Ocular manifestationsOcular manifestations include:include:
 colobomas of the iris,colobomas of the iris,
choroid and optic nerve.choroid and optic nerve.
 microphthalmia.microphthalmia.
 strabismus.strabismus.

59. Thanks